Module 10
Questions
1. 1.ID: 283570154
A nurse provides dietary instructions to the mother of a child with celiac disease. Which of the
following foods does the nurse tell the mother to include in the child’s diet?
• Rice Correct
• Wheat cereal
• Rye crackers
• Oatmeal biscuits
Rationale: Dietary management is the mainstay of treatment in celiac disease. All wheat,
rye, barley, and oats should be eliminated from the diet and replaced with corn and rice.
Vitamin supplements, especially fat-soluble vitamins and folate, may be needed in the early
period of treatment to correct deficiencies. Dietary restrictions are likely to be lifelong,
although small amounts of grains may be tolerated after the ulcerations have healed.
Test-Taking Strategy: Use the process of elimination and knowledge regarding the dietary
management of celiac disease to answer this question. Recalling that corn and rice are
substitutes for gluten-containing foods in this disease will direct you to the correct option.
Review dietary management of celiac disease if you had difficulty with this question.
Reference: McKinney, E., James, S., Murray, S., & Ashwill, J. (2009). Maternal-child nursing (3rd
ed., p. 1129). St. Louis: Elsevier.
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Teaching and Learning
Content Area: Child Health –
Gastrointestinal
, Awarded 1.0 points out of 1.0 possible points.
2. 2.ID: 283570766
A nurse in the newborn nursery is monitoring a neonate born to a mother with diabetes
mellitus. For which of the following findings does the nurse monitor the neonate most closely?
• Hypercalcemia Incorrect
• Hyperglycemia
• Hypobilirubinemia
• Respiratory distress syndrome Correct
Rationale: The major neonatal complications of preexisting diabetes mellitus in the mother are
hypoglycemia, hypocalcemia, hyperbilirubinemia, and respiratory distress syndrome. The
infant of a diabetic mother is more likely to have delayed production of pulmonary surfactant,
which is needed to keep the alveoli open after birth.
Test-Taking Strategy: Use the process of elimination. Focusing on the mother’s diagnosis will
assist you in eliminating the incorrect options. Also, thinking about the pathophysiology of
diabetes mellitus and recalling that the infant is likely to have delayed production of pulmonary
surfactant will direct you to the correct option. Review the effects of maternal diabetes
mellitus on the fetus if you had difficulty with this question.
Reference: McKinney, E., James, S., Murray, S., & Ashwill, J. (2009). Maternal-child nursing (3rd
ed., p. 755). St. Louis: Elsevier.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Assessment
Content Area: Newborn
Awarded 0.0 points out of 1.0 possible points.
3. 3.ID: 283569874
,The nurse has instructed a client who is about to begin external radiation therapy in how to
maintain optimal skin integrity during therapy. Which statement by the client indicates a need
for further instruction?
• “I need to keep the sun off the radiation site.” Incorrect
• “I can use over-the-counter cortisone cream on the radiation site if it gets red.” Correct
• “I need to be careful not to wash off the marks that the radiologist made on my skin.”
• “I need to wash the skin at the radiation site with a mild soap and water and pat it dry.”
Rationale: The client should use no powders, ointments, lotions, or creams on the skin at the
radiation site unless they have been prescribed by the physician. Avoiding sun exposure of the
radiation site, not removing marks made on the skin by the radiologist, and washing the skin
with mild soap and water and patting it dry are all correct measures. The client should also be
instructed to avoid using harsh detergents to wash clothing.
Test-Taking Strategy: Note the strategic words “need for further instruction” in the query of
the question, which indicate a negative event query and the need to select the incorrect client
statement. Noting the words “over-the-counter” will direct you to the correct option. Review
client teaching points for skin care during radiation therapy if you had difficulty with this
question.
References: Black, J., & Hawks, J. (2009). Medical-surgical nursing: Clinical management for
positive outcomes (8th ed., p. 277). St. Louis: Saunders.
Lewis, S., Dirksen, S., Heitkemper, M., Bucher, L., & Camera, I. (2011). Medical-surgical nursing:
Assessment and management of clinical problems (8th ed., p. 285). St. Louis: Mosby.
Level of Cognitive Ability: Evaluating
Client Needs: Physiological Integrity
Integrated Process: Teaching and
Learning Content Area: Adult
Health/Oncology
Awarded 0.0 points out of 1.0 possible points.
, 4. 4.ID: 283572062
The nurse is administering cardiopulmonary resuscitation (CPR) to an adult client.
Which compression-ventilation ratio is correct?
• 15:1 Incorrect
• 15:2
• 20:2
• 30:2 Correct
Rationale: A 30:2 ratio of compressions to ventilations is recommended for CPR in adults. The
other options are incorrect.
Test-Taking Strategy: Knowledge regarding the procedure for performing CPR on an adult client
is needed to answer this question. Remember that the 30:2 ratio of compressions to ventilations
is recommended for CPR in adults. Review this procedure if you had difficulty with this question.
Reference: Berg, R. A., et al. (2010). American Heart Association guidelines for cardiopulmonary
resuscitation and emergency cardiovascular care, Circulation 122: S685-S705. Available online at
http://circ.ahajournals.org/cgi/reprint/122/18_suppl_3/S685.
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Critical Care
Awarded 0.0 points out of 1.0 possible points.
5. 5.ID: 283571189
Mastitis is diagnosed in a client who recently gave birth. The nurse tells the woman that:
Questions
1. 1.ID: 283570154
A nurse provides dietary instructions to the mother of a child with celiac disease. Which of the
following foods does the nurse tell the mother to include in the child’s diet?
• Rice Correct
• Wheat cereal
• Rye crackers
• Oatmeal biscuits
Rationale: Dietary management is the mainstay of treatment in celiac disease. All wheat,
rye, barley, and oats should be eliminated from the diet and replaced with corn and rice.
Vitamin supplements, especially fat-soluble vitamins and folate, may be needed in the early
period of treatment to correct deficiencies. Dietary restrictions are likely to be lifelong,
although small amounts of grains may be tolerated after the ulcerations have healed.
Test-Taking Strategy: Use the process of elimination and knowledge regarding the dietary
management of celiac disease to answer this question. Recalling that corn and rice are
substitutes for gluten-containing foods in this disease will direct you to the correct option.
Review dietary management of celiac disease if you had difficulty with this question.
Reference: McKinney, E., James, S., Murray, S., & Ashwill, J. (2009). Maternal-child nursing (3rd
ed., p. 1129). St. Louis: Elsevier.
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Teaching and Learning
Content Area: Child Health –
Gastrointestinal
, Awarded 1.0 points out of 1.0 possible points.
2. 2.ID: 283570766
A nurse in the newborn nursery is monitoring a neonate born to a mother with diabetes
mellitus. For which of the following findings does the nurse monitor the neonate most closely?
• Hypercalcemia Incorrect
• Hyperglycemia
• Hypobilirubinemia
• Respiratory distress syndrome Correct
Rationale: The major neonatal complications of preexisting diabetes mellitus in the mother are
hypoglycemia, hypocalcemia, hyperbilirubinemia, and respiratory distress syndrome. The
infant of a diabetic mother is more likely to have delayed production of pulmonary surfactant,
which is needed to keep the alveoli open after birth.
Test-Taking Strategy: Use the process of elimination. Focusing on the mother’s diagnosis will
assist you in eliminating the incorrect options. Also, thinking about the pathophysiology of
diabetes mellitus and recalling that the infant is likely to have delayed production of pulmonary
surfactant will direct you to the correct option. Review the effects of maternal diabetes
mellitus on the fetus if you had difficulty with this question.
Reference: McKinney, E., James, S., Murray, S., & Ashwill, J. (2009). Maternal-child nursing (3rd
ed., p. 755). St. Louis: Elsevier.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Assessment
Content Area: Newborn
Awarded 0.0 points out of 1.0 possible points.
3. 3.ID: 283569874
,The nurse has instructed a client who is about to begin external radiation therapy in how to
maintain optimal skin integrity during therapy. Which statement by the client indicates a need
for further instruction?
• “I need to keep the sun off the radiation site.” Incorrect
• “I can use over-the-counter cortisone cream on the radiation site if it gets red.” Correct
• “I need to be careful not to wash off the marks that the radiologist made on my skin.”
• “I need to wash the skin at the radiation site with a mild soap and water and pat it dry.”
Rationale: The client should use no powders, ointments, lotions, or creams on the skin at the
radiation site unless they have been prescribed by the physician. Avoiding sun exposure of the
radiation site, not removing marks made on the skin by the radiologist, and washing the skin
with mild soap and water and patting it dry are all correct measures. The client should also be
instructed to avoid using harsh detergents to wash clothing.
Test-Taking Strategy: Note the strategic words “need for further instruction” in the query of
the question, which indicate a negative event query and the need to select the incorrect client
statement. Noting the words “over-the-counter” will direct you to the correct option. Review
client teaching points for skin care during radiation therapy if you had difficulty with this
question.
References: Black, J., & Hawks, J. (2009). Medical-surgical nursing: Clinical management for
positive outcomes (8th ed., p. 277). St. Louis: Saunders.
Lewis, S., Dirksen, S., Heitkemper, M., Bucher, L., & Camera, I. (2011). Medical-surgical nursing:
Assessment and management of clinical problems (8th ed., p. 285). St. Louis: Mosby.
Level of Cognitive Ability: Evaluating
Client Needs: Physiological Integrity
Integrated Process: Teaching and
Learning Content Area: Adult
Health/Oncology
Awarded 0.0 points out of 1.0 possible points.
, 4. 4.ID: 283572062
The nurse is administering cardiopulmonary resuscitation (CPR) to an adult client.
Which compression-ventilation ratio is correct?
• 15:1 Incorrect
• 15:2
• 20:2
• 30:2 Correct
Rationale: A 30:2 ratio of compressions to ventilations is recommended for CPR in adults. The
other options are incorrect.
Test-Taking Strategy: Knowledge regarding the procedure for performing CPR on an adult client
is needed to answer this question. Remember that the 30:2 ratio of compressions to ventilations
is recommended for CPR in adults. Review this procedure if you had difficulty with this question.
Reference: Berg, R. A., et al. (2010). American Heart Association guidelines for cardiopulmonary
resuscitation and emergency cardiovascular care, Circulation 122: S685-S705. Available online at
http://circ.ahajournals.org/cgi/reprint/122/18_suppl_3/S685.
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Critical Care
Awarded 0.0 points out of 1.0 possible points.
5. 5.ID: 283571189
Mastitis is diagnosed in a client who recently gave birth. The nurse tells the woman that:
